NTSB Says Pilot Error Caused Comair Flight 5191 Crash That Killed 49

WASHINGTON (AP) - Pilots' failure to notice clues that they wereheading to the wrong runway was the primary cause of last summer'sdeadly Kentucky plane crash that killed 49 people, safetyinvestigators concluded Thursday. The National Transportation Safety Board deliberated all day onpossible causes of the Aug. 27, 2006, crash of Comair Flight 5191,which tried to depart in the pre-dawn darkness from an unlitgeneral aviation strip too short for a proper takeoff. Board members originally had considered listing errors by theair traffic controller as contributing causes but ultimately pinnedmost of the blame on the pilots, along with the Federal AviationAdministration for failing to enforce earlier recommendations onrunway checks. NTSB board member Deborah Hersman suggested during the meetingthat there were numerous causes - nearly all of them human. "That's the frustration of this accident - no single cause, nosingle solution and no 'aha' moment," Hersman said. "Rather thanpointing to a mechanical or design flaw in the aircraft that couldbe fixed or a maintenance problem that could be corrected, thisaccident has led us into the briar patch of human behavior." Hersman was one of two board members who voted to list thecontroller's action as a contributing cause, but she was overruled. The NTSB also proposed several changes to aviation procedure asa result of the accident, including calls for clearer signs atregional airports and installation of an automated moving mapsystem in which pilots can check in real time whether they're onthe right runway. In a statement, Comair President Don Bornhorst said he wouldwork with the NTSB and the FAA to address the proposed changes. The board's findings were perhaps more notable for the thingsthey decided weren't factors than the ones they determined were. Among the non-factors, according to the board, were the flightcrew's lack of updated maps and notices alerting them toconstruction that had changed the taxiway route a week earlier.Although the board found the controller was fatigued, that alsolikely didn't play a role, the board said. Pilot Jeffrey Clay and first officer James Polehinke were mostculpable for ignoring clear signs they were going the wrong way,such as the lack of lights on the shorter runway, NTSB found."Weird, no lights," Polehinke was quoted as saying in the cockpittranscript. NTSB chairman Mark Rosenker said afterward there were cleardifferences between the right strip and the wrong one. "One was lit up like a Christmas tree," he said. "The otherwas like a black hole." Polehinke was pulled from the charred cockpit as the onlysurvivor, but he sustained brain damage, lost a leg and brokenumerous bones. His attorney, Bruce Brandon, declined commentThursday. A secondary cause, NTSB said, was non-pertinent chatter betweenthe crew members as they prepared to taxi and take off. Comair hasacknowledged some culpability as a result of the talk, whichviolated FAA rules calling for a "sterile cockpit." NTSB staff concluded the talk "greatly affected the crew'sperformance." Hersman agreed but suggested the disaster couldn'tbe pinned on that alone. "It's clear this crew made a mistake," Hersman said. "Theirheads just weren't in the game here. The issue is, what enabledthem to make this mistake?" Hersman pointed to the paperwork the crew never got detailingthe taxiway change. Not only was it not in their packet fromComair, but the air traffic controller didn't broadcast theannouncement that morning, even though it had been doing so therest of the week. "We deal in redundancies in this business," Rosenker said."That's what enables us to look after each other in the cockpit,and if one of the crewmen fails to do something, the other is thereto help fill in the gap." No witnesses were called at the board meeting. Investigators said a lone air traffic controller on duty usedpoor judgment by turning his back before takeoff, but they debatedwhether a required second controller could have prevented theaccident. NTSB staff concluded controller Christopher Damron should neverhave turned away to do an administrative task "not critical toflight safety" as the jet was preparing to depart. However, the staff dismissed as a non-factor the violation of anFAA directive calling for two controllers to work overnight shiftsin airports like Lexington - one to keep an eye on the ground, theother to monitor radar. Patrick R. Forrey, president of the National Air TrafficControllers Association, said there was nothing Damron should havedone differently. He said the error that happened in the tower wasdue to staffing. "He would have had the opportunity to possibly catch thataircraft from going down the wrong runway," Forrey said. Among the family members who attended the proceedings wasLexington resident Kathy Ryan, who lost her husband Michael in theaccident. She said she agreed with most of the findings but thatthe meeting was difficult to endure. "You relive the accident and you also relive the week ofbriefings," Ryan said. "It was like being back there againtoday." About 25 relatives of crash victims gathered at a hotel indowntown Lexington on Thursday to watch a video link to thehearing. "You just think that if one precaution had been observed, thenthis tragedy wouldn't have happened, and we would still have ourloved ones," said Lois Turner, whose husband was a passenger."And that, I think, is the sad part and the hard part, to knowthat there were so many missed opportunities." --- Associated Press writers Ann Sanner in Washington and Joe Bieskin Lexington contributed to this report. --- On the Net: NTSB report: http://www.ntsb.gov/Publictn/2007/AAR-07-05.htm

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